Osteoarticular Allograft for Reconstruction of Acute Distal Humerus Fractures With Massive Bone Loss

Abstract

Introduction: Reconstruction of the elbow with restoration of function can be challenging, particularly with large osseous defects created from tumor resection or trauma. Osteoarticular allograft reconstruction is an option in patients with massive periarticular elbow bone loss secondary to tumor surgery or trauma. Surgical reconstruction of a posttraumatic elbow with extensive bone loss remains a challenging problem. The clinical success with osteoarticular allograft reconstruction has been documented in several series of oncological limb salvage surgery; but reports of using hemiarticular elbow allografts in the reconstruction of postraumatic elbows are few. Objective: To present a clinical case of a 46-year-old female patient with open (Gustilo 1) Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C3 fracture of the distal humerus after high-energy trauma, treated operatively with the use of osteoarticular allograft to restore posttraumatic articular defects and massive bone loss, and to perform a bibliographic review. Materials and Methods: We report our experience with hemiarticular elbow allograft reconstructions after severe elbow trauma in a young patient, as first treatment. An extensive resection of distal humerus was performed through a posterior approach with Chevron osteotomy. The defect was reconstructed with distal humerus osteoarticular allograft with a stable internal fixation with compression plates and screws. Patient’s epicondyles with collateral ligaments and tendon insertions were carefully preserved and fixed with mini-screws. The ulnar nerve was transposed anteriorly. Results: At a follow-up of 30 months, the arc of motion was 120° and the rotational arc of motion was 100°, without clinical complications. The Mayo Elbow Performance Score and the Disabilities of Arm, Shoulder and Hand (DASH) questionnaire, used to assess clinical outcomes and patient satisfaction, were satisfactory. Radiographic results demonstrated radiographic incorporation of the allograft with the maintenance of the joint congruity. Conclusions: Management of a posttraumatic elbow injury with significant articular defects and deficient bone can pose a major reconstructive challenge and is especially concerning given the increased frequency of such injuries as a result of an escalating rate of high-energy trauma among young adults. Large bone allograft transplants have been successfully used to reconstruct skeletal defects created by tumor resections and failed arthroplasties, but little has been reported on their use in traumatic defects. The reconstruction of distal humerus with osteoarticular allograft respecting the autogenous collateral ligaments is a viable alternative in salvage situations involving massive bone loss and young patients who are not conventional candidates for total elbow arthroplasty. The preservation of collateral ligaments in conjunction with tendon insertions, at the short-term observation, may improve elbow stability. This study suggests that large bone allografts are of value in reconstructing traumatic skeletal defects, especially those involving an articular surface in a young patient. However, long-term results are still unknown. Although not recommended for routine use, this operation is viewed as a salvage procedure.